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Insurance company faces pushback for ER coverage policy change

Patients are fighting to reverse Anthem's policy of denying coverage for ER visits they do not deem necessary


By Koby Levin
The Joplin Globe

CARTHAGE, Mo. — Jana Smith is careful with her heart.

By taking cholesterol medication and walking 10,000 steps a day, Smith has made it to age 38, making her older by several years than her mother and grandmother when they died of heart attacks.

Born with narrow arteries, she lives with the specter of chest pain and the heart attack it could portend. If that day ever arrives, Smith plans to go to the emergency room. She just hopes she won’t have to worry about paying the bills.

Anthem, the nation's second-largest insurer, recently became the first company in Missouri to review emergency room charges after the fact. If the company determines that the visit was necessary — as in, say, an actual heart attack — it will pay its share of the bills. But if the visit doesn’t amount to more than heartburn, Anthem could deny coverage and those bills, which could amount to thousands of dollars even for a false alarm, could be the responsibility of the patient.

Smith and other patient advocates are pushing back, fighting to reverse Anthem's effort and to make sure other insurers don't adopt the same policy.

They have the support of some Missouri lawmakers who want to outlaw it — including state Rep. Cody Smith, R-Carthage, Jana's husband — and the American Heart Association.

“Time is of the essence when it comes to a heart attack,” Jana said. “If people are afraid that they’ll have to pay hundreds or even thousands of dollars to go to the ER, they’re not going to go unless they really think they’re having an emergency.”

Policy revised

Last year, customers in Missouri and Georgia started getting letters from Anthem warning them that minor complaints should be checked out at places like clinics or urgent care centers, where visits can cost $85 and $190, respectively. By comparison, Anthem says a typical ER visit can run into the four figures.

The ER should be used "as it was designed — to treat life-threatening illness," Dr. Craig Samitt, Anthem's chief clinical officer, said last year when the policy became public. "This is in no way meant to compromise a member's determination of whether they've got an emergency."

Samitt said at the time that Anthem wasn't simply rejecting every non-urgent ER claim it received. The insurer has a physician review a case before issuing a denial and would consider a patient's circumstances. Anthem said it may cover a patient who arrives with chest pains that turn out to be indigestion instead of a heart attack. However, hospital officials in Missouri say many of Anthem's reviews haven't been thorough. The insurer was accused of rejecting some claims in only a couple days and in some cases hadn't even requested patient records before making a decision, according to Daniel Landon, a senior vice president with the Missouri Hospital Association.

In a statement responding to a Globe request for an interview, Scott Golden, an Anthem spokesperson, said: “Emergency rooms are an expensive place to receive care. The costs of treating nonemergency ailments in the ER has an impact on the cost of health care for consumers, employers and the health care system as a whole.”

Anthem hoped its new policy would dissuade patients from needlessly visiting the ER, but the company faces blowback from lawmakers, hospital groups, patients and those like Smith. Last month, Anthem announced tweaks to the policy, outlining a number of scenarios in which it said it will always cover emergency care.

For instance, if the patient receives an MRI or CT scan during an emergency room visit, Anthem will pay for the visit under the revised protocol. The same goes for patients under 15 years old, patients who live more than 15 miles from an urgent care center, and patients who were directed to the ER by an ambulance crew, among other “always pay” scenarios.

That list is still being reviewed and could be expanded further, Golden said.

Legal fix

But those changes don’t persuade groups such as the American Heart Association, which has gotten behind a Missouri bill that would outlaw Anthem’s policy and others like it.

Karen Englert, the group’s government relations director in Missouri, says even the revised policy puts cardiac patients at risk. She worries that other companies will follow Anthem’s precedent. UnitedHealth, the nation's largest insurer, began a similar policy this week for some of its patients.

“Our concern is that if this is allowed to continue, it really could compromise health for so many people,” Englert said. “(Anthem) could be the first of many insurers to adopt this policy.”

She added that the potential cost of an ER visit could discourage some cardiac patients from visiting the ER when they believe they may be having a heart attack. A basic visit to the ER at Mercy in Joplin ranges in cost from $450 to to $1,300, excluding tests and physician fees, according to a hospital spokeswoman.

“When (chest pain) is happening, a person should be just concerned with their health,” Englert said.

ER costs are the focus of several bills currently under debate at the state capital. Two bills attempt to bring down the cost of ER visits by adjusting incentives for insurers and hospitals. A third bill, proposed by state Sen. Paul Wieland, R-Imperial, garnered the support of the AHA for its patient-centered approach. It defines an “emergency medical condition” based on symptoms — not a doctor’s ultimate diagnosis — effectively rendering Anthem's policy illegal.

Cody Smith plans to support the bill if it passes the senate, although he is concerned about emergency room costs.

"It's a huge cost-driver for everyone in health care," he said. "But I don’t believe that (Anthem's policy) is the best way to chip away at that problem."

The bill will be debated this week by the full Missouri senate after receiving a unanimous "yes" vote in committee. Support for the bill goes beyond the American Heart Association. In a March 5 letter to an Anthem executive, which was obtained by the Globe, the executive director of the American Hospital Association expressed concerns about the company’s policy and not just with heart attacks, but with other medical emergencies. Thomas P. Nickels, pointed to the story of a Kentucky woman who was billed $12,000 after going to the ER with symptoms that she incorrectly attributed to appendicitis.

The woman, who’s story was first reported by Vox, received the same letter as many Anthem patients.

“Emergency room services can be approved ... when a health problem is recent and severe enough that it needs immediate care such as a stroke, heart attack or severe bleeding,” reads the letter, which was obtained by the Globe.

Under Anthem’s revised policy, the woman’s ER visit would have been covered because she received a CT scan and an ultrasound.

Still, Nickels called the policy “dangerous,” adding that “Anthem’s policy puts the patient in the position of knowing their diagnosis before seeking care.”

Family matter

Jana Smith was 16 when her mother died of a heart attack at the age of 34. Her grandmother died at age 31, and she had an aunt who needed quadruple bypass surgery at age 33.

At 23, Jana visited a cardiologist, who sent her test results to the Mayo Clinic for closer analysis. Today, she is healthy, thanks to cholesterol medications and a regular exercise regimen. She volunteers for the American Heart Association to help patients with heart problems. She notes that heart disease is the leading killer of women in the U.S.

She also points out that that for decades, the American Heart Association has educated the public to take heart attack symptoms seriously, to call 911 and to get immediate medical attention, and she's worried that Anthem's policy will undo all that effort, leading to more preventable deaths.

But she worries that people in her situation won’t recognize the problem soon enough, particularly if Anthem’s ER policy becomes widespread. During an emergency, she only wants the patents to be concerned about their health, not the bills.

“That’s going to deter some people from going to the emergency room,” she said. “And even if you’re not having a heart attack, there still could be warning signs.”

State by state

Anthem, a national health insurance company, has rolled out a controversial ER billing policy in Georgia, Missouri, Ohio, Indiana, New Hampshire and Kentucky.

Several Georgia hospitals sued the insurer after it stopped paying for some imaging tests.

In Ohio, as in Missouri, lawmakers are pushing a bill that would outlaw the policy.

Copyright 2018 The Joplin Globe

McClatchy-Tribune News Service

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